By Dale E. Hocking, CPA, VP & CFO, Jupiter Health, Inc
I have been a CFO in healthcare for 30 years, I’ve seen a lot of revenue cycle issues that are new and a lot that are recurring and never seem to get fully resolved. Healthcare is changing so fast that keeping up is critical and technology can make a significant difference.
Let’s start at the front-end, scheduling a patient. Technology is available that allows patients and physicians to schedule procedures without any assistance from hospital staff. This technology can be a simple as downloading an app on your phone and using it to schedule tests and or procedures. This saves a lot of labor time for the healthcare system and increases patient and physician satisfaction. Not all hospitals have this capability. Many front-end systems don’t interface with each other very well. There are ways to have these systems “talk” to each other.
Hire appropriate leaders, set up the proper structure, provide the necessary technology, and ensure the team members are well trained.
Health systems continue to have challenges with denials. No matter how good a health system is with preventing and overturning denials, the payors will continue to find new ways to deny or recoup payments that have been earned by the providers. Many providers continue to purchase expensive denial management systems to track and trend denials. Some systems have incredible metrics and graphics that help you determine the root cause of these denials and underpayments. I have found that others don’t do a very good job in determining whether a denial really exists. Providers also deal with disparate systems. Many patient accounting and denial systems don’t talk to each other.
Over 20 years ago, Providers wrote scripts and keystroke emulation to trick computers to think a person was sitting at a keyboard. Today they call it Robotic Process Automation (RPA) and companies charge a lot of money for RPA to interface systems. RPA has been around for quite a long time under other names. Fully integrated systems were difficult to come by years ago, but now are available. However, RPA may help the Providers that can’t afford to replace systems.
There are newer technologies that are becoming more available. Artificial Intelligence (AI) is one of them. Most providers are not yet taking advantage of what AI can do. For those providers that embrace AI, this technology can learn and improve processes. Bi-directional interfaces are also more common now. These systems and tools make it possible to have high-performing revenue cycles.
There are so many other issues to deal with in the revenue cycle, such as upfront collections, payor contracting, and medical necessity, that I have not even mentioned. Each is important and needs attention.
COVID-19 has created turmoil in the healthcare industry, certainly more than ever before in my career. Staffing is extremely difficult and is very expensive due to higher wages, travelers, sign-on bonuses, and more. Social distancing at work has created even more issues since most organizations don’t have as much space as they need. Today, we need almost twice the space for the same number of people. The revenue cycle is not exempt from staffing shortages.
Unvaccinated team members continue to isolate at home for a couple of weeks when they contract COVID-19 or are exposed to others that may have been infected. Government subsidies have made it increasingly difficult for Providers to hire entry-level staff.
There is also the issue of team members preferring remote work, whether at home or the beach. Many organizations have worked on improving their culture for many years and they may be finding that their culture is eroding, and customer service is suffering. How do you instill a culture when your team members never interface with the others they work with, except over the phone, or through virtual meetings?
COVID-19 also impacted collection activity. Some Providers stopped billing patients for their financial portion as a sense of community responsibility, and then at some point had to restart that process. Reimbursement also changed because of COVID-19. Medicare paid for uninsured patients with COVID-19 and also added an additional 20 percent payment for patients with COVID-19. Providers need to ensure that they receive these payments. Many expensive drugs provided to patients with COVID-19, like Remdesivir, are reimbursed by Medicare, in addition to the DRG or APC payment. However, the right “J” codes must be used appropriately. The Charge Description Master must have the appropriate codes, the coding teams need to ensure the codes are on the bill, and the collection teams must ensure these payments are received. The revenue integrity team also should have the responsibility to ensure the appropriate processes and procedures are in place to receive the appropriate revenue.
Let’s not forget about Clinical Documentation Improvement (CDI). There is a tremendous amount of revenue that may be left on the table if the clinical documentation in the medical record lacks proper wording. Technology has helped physicians answer queries from the CDI team more efficiently and timely. Now physicians can even respond to the queries on their cell phones.
As you can see, there is a lot to do in the revenue cycle to ensure your organization is paid appropriately. Things continue to change, and I don’t think this will slow down. Hire appropriate leaders, set up the proper structure, provide the necessary technology, and ensure the team members are well trained. Don’t forget how vital it is to measure and monitor the results on an ongoing basis. With all that in place, you will help to ensure the financial viability of your organization.